Ch.15, Neurodevelopmental Disorders Flashcards
developmental psychopathology
focuses on determining what is abnormal at any point in the developmental process by comparing and contrasting it with normal and expected changes that occur.
-It is important to note that there is no sharp line of demarcation between the maladaptive behavior patterns of childhood and those of adolescence (i.e., no precise age at which temper tantrums are now considered officially “abnormal”), or between those of adolescence and those of adulthood.
considerations in childhood pathology
They do not have as complex and realistic a view of themselves and their world as they will have later, and they have not yet developed a stable sense of identity or a clear understanding of what is expected of them and what resources they might have to deal with problems.
Immediately perceived threats are tempered less by considerations of the past or future and thus tend to be seen as disproportionately important. As a result, children often have more difficulty than adults in coping with stressful events (Compas et al., 2017).
Children’s lack of experience in dealing with adversity can make manageable problems seem insurmountable (Scott et al., 2010). For instance, one of the authors of this book thought the world would literally end when he didn’t attend his junior prom. (Spoiler alert: It did not.)
Children also are more dependent on other people than are adults. Although in some ways this dependency serves as a buffer against other dangers because the adults around him or her might “protect” a child against stressors in the environment, it also makes the child highly vulnerable to abuse or neglect by others.
childhood vs adult classifications DSM
The greatest problem was that the same classification system that had been developed for adults was used for childhood problems even though many childhood disorders, such as autism, learning disabilities, and school phobias, have no counterpart in adult psychopathology. The early systems also ignored the fact that in childhood disorders, environmental factors play an important part in the expression of symptoms—that is, symptoms are highly influenced by a family’s acceptance or rejection of the behavior. In addition, symptoms were not considered with respect to a child’s developmental level. Some behaviors that the DSM defined as problematic could be considered to be age-appropriate ones that would eventually be outgrown (e.g., fears, temper tantrums). All of these concerns are fully addressed in the DSM-5.
Anxiety disorders
are the most common mental disorder among children and adolescents, occurring at some point in the lifetime of approximately 32 percent of U.S. youth
They occur at higher rates among girls (38 percent) than boys (26 percent), and most commonly take the form of specific phobias (19 percent), social anxiety disorder (9 percent), separation anxiety disorder (8 percent), and posttraumatic stress disorder (5 percent)
Separation anxiety disorder,
lassified under anxiety disorders in DSM-5, is characterized by excessive anxiety about separation from major attachment figures, such as mothers, and from familiar home surroundings (Bernstein & Layne, 2006). Children with separation anxiety disorder often lack self-confidence, are apprehensive in new situations, and tend to be immature for their age. Such children are described by their parents as shy, sensitive, nervous, submissive, easily discouraged, worried, and frequently moved to tears. In many cases, a clear psychosocial stressor can be identified, such as the death of a relative or a pet. The following case study illustrates the clinical picture in this disorder.
Causes of childhood anxiety disorders
-Anxious children often show an early sensitivity that makes them easily conditionable by aversive stimuli.
- They then have a harder time calming down, a fact that can result in a buildup and generalization of surplus fear reactions. The child can become anxious because of early illnesses, accidents, or losses that involved pain and discomfort. The traumatic effect of experiences such as hospitalizations makes such children feel insecure and inadequate. The traumatic nature of certain life changes such as moving away from friends and into a new situation can also have an intensely negative effect on a child’s adjustment. Overanxious children often have the modeling effect of an overanxious and protective parent who sensitizes a child to the dangers and threats of the outside world. Often, the parent’s overprotectiveness communicates a lack of confidence in the child’s ability to cope, thus reinforcing the child’s feelings of inadequacy
parental attachment and childhood anxiety disorders
Years of research on the relationships between young children and their parents suggest that there seem to be sensitive periods during which, if parental attachment figures provide support and security to their children in the face of perceived threats, the child learns how to use social relationships with close others to reduce stress. Whereas, a failure of the parental attachment figure to provide such support and security might hinder the child’s ability to learn to use social support, decrease the child’s ability to control their natural stress response, and increase the risk of future anxiety problems
treatments for childhood anxiety disorders
Cognitive-behavior therapy (CBT) has been shown to be highly effective at reducing anxiety symptoms in young children, with approximately two-thirds of children and adolescents showing significant improvement from this treatment
Using this approach, the clinician tailors the treatment to a child’s particular problem and uses psychoeducation about fear and anxiety, systematic and gradual exposure to the anxiety-provoking stimulus, and positive reinforcement for repeated and prolonged exposure as a means of decreasing the child’s anxiety about the feared object or situation. Exposure-based therapies have proven to be quite effective in the treatment of adult, adolescent, and child anxiety.
Psychopharmacological treatment of anxiety disorders in children and adolescents has become more common over the past few decades (Vitiello & Waslick, 2010). In general, the same medications used to treat adult anxiety disorders are used in the treatment of children and adolescents. The most commonly used medications are benzodiazepines, which rapidly inhibit the central nervous system (CNS), providing a calming effect, and selective serotonin reuptake inhibitors, which increase the availability of serotonin over time
depression diagnosis children vs adults
Childhood depression, like depression in adults, is characterized by symptoms of sadness, withdrawal, crying, poor sleep and appetite, and in some cases thoughts of suicide or suicide attempts. In the past, childhood depression was classified according to essentially the same DSM diagnostic criteria used for adults. One modification used for diagnosing depression in children is that irritability is often found as a major symptom and can be substituted for depressed mood.
Depression in children and adolescents occurs with high frequency. Approximately 12 percent of children and adolescents meet criteria for major depression at some point in their lives, with higher rates in girls (16 percent) than boys (8 percent) (Merikangas et al., 2010). These rates have been generally consistent during the past several decades (Costello et al., 2006). Although depression can occur in children, the rates are low during childhood but increase dramatically during adolescence.
rise in bipolar cases with children vs adolescents
There are several potential explanations for this increase. It could reflect a true increase in the disorder in young people. Or, it could be that the rate of bipolar disorder was always high but unrecognized, and with increased awareness practitioners are now recognizing more patients with the disorder that they had “missed” in the past. A third possibility is that clinicians are using the bipolar diagnosis more liberally now than in the past and are erroneously increasing the application of the diagnosis to a wide range of behavior problems, for example, attention-deficit/hyperactivity disorder (ADHD). Many experts support this last possibility. For instance, children and adolescents diagnosed with bipolar disorder are much more likely than adults with such diagnoses to be male (67 percent versus 32 percent) and to have a comorbid diagnosis of ADHD (32 percent versus 3 percent)
causes of depressive disorders childhood
There appears to be an association between parental depression and behavioral and mood problems in children. Children of parents with major depression are more impaired, receive more psychological treatment, and have more psychological diagnoses than children of parents with no psychological disorder
- biological changes in the neonate as a result of alcohol intake by the mother during pregnancy, because prenatal exposure to alcohol is related to depression in children. M. J. O’Connor’s (2001) study of children exposed to alcohol in utero reveals continuity between alcohol use by the mother and infant negative affect and early childhood depression symptoms.
-The experience of negative life events and the learning of maladaptive behaviors appear to be important in childhood depressive disorders. A number of studies have indicated that children’s exposure to early traumatic events can increase their risk for the development of depression. Children who have experienced past stressful events are susceptible to states of depression that make them vulnerable to suicidal thinking under stress
- Intense or persistent sensitization of the central nervous system in response to severe stress might induce hyperreactivity and alteration of the neurotransmitter system, leaving these children vulnerable to later depression
-Children who are exposed to negative parental behavior or negative emotional states may develop depressed affects themselves. Investigators have been evaluating the possibility that mothers who are depressed transfer their low mood to their infants through their interactions with them. This can happen through multiple pathways, including modeling of depressive behavior, lack of responsiveness of the parent to the child’s behavior, or through more biological channels.
depression and oxytocin in mothers
those with depression showed lower levels of oxytocin (the so-called “love hormone” that increases during social bonding) in general, and in response to interactions with their newborns. Moreover, the newborns of depressed mothers showed oxytocin levels that correlated with those of their mothers, suggesting that the levels may be influenced by such interactions
treatment of depression childhood
Antidepressants are among the most widely used drugs in treating child and adolescent mental disorders (Emslie et al., 2010). Unfortunately, research on the effectiveness of antidepressant medications with children has been mixed. Some studies of adolescents with depression have suggested that antidepressants such as fluoxetine (Prozac) are more effective than a placebo (Treatment for Adolescents with Depression Study Team, U.S., 2004). On the other hand, in addition to having some undesirable somatic side effects (nausea, headaches, nervousness, insomnia, and even seizures) in children and adolescents, some research has suggested that antidepressant medication treatment in children and adolescents is associated with an increased risk of suicidal thoughts and behaviors
Juvenile delinquency
legal term used to refer to violations of the law committed by minors
Oppositional defiant disorder (ODD)
is characterized by a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months. ODD is grouped into three subtypes: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. This disorder usually begins by the age of 8 and has a lifetime prevalence of 10 percent, with a slightly higher rate among boys (11 percent) than girls (9 percent)
Conduct disorder (CD)
Statistical analyses that examine how symptoms cluster together have revealed the presence of five common subtypes of CD, with each made up of children engaging primarily in (1) rule violations (26 percent of those with CD), (2) deceit/theft (13 percent), (3) aggressive behavior (3 percent), (4) severe forms of subtypes 1 and 2 (29 percent), and (5) a combination of subtypes 1, 2, and 3 (29 percent)
Children and adolescents with CD are also frequently comorbid for other disorders such as substance abuse disorder (Goldstein et al., 2006) or depressive symptoms (Stalk et al., 2015). CD significantly increases the risk of pregnancy and substance abuse in teenage girls and of the later development of antisocial personality disorder and a range of other disorders
early onset CD causes
Evidence has accumulated that a genetic predisposition leading to low verbal intelligence, mild neuropsychological problems, and difficult temperament can set the stage for early-onset CD (Simonoff, 2001). Researchers also have found strong heritable effects of conduct problems and antisocial behavior across ethnically and economically diverse samples (Baker et al., 2007). The child’s difficult temperament may lead to an insecure attachment because parents find it hard to engage in the good parenting that would promote a secure attachment. In addition, the low verbal intelligence and mild neuropsychological deficits that have been documented in many of these children—some of which may involve deficiencies in self-control functions such as sustaining attention, planning, self-monitoring, and inhibiting unsuccessful or impulsive behaviors—may help set the stage for a lifelong course of difficulties
Age of CD Onset and Links to Antisocial Personality Disorder
Children who develop CD at an earlier age are much more likely to develop psychopathy or antisocial personality disorder as adults than are adolescents who develop CD suddenly in adolescence (Copeland et al., 2007). The link between CD and antisocial personality is stronger among lower-socioeconomic-class children (Lahey et al., 2005). It is the pervasiveness of the problems first associated with ODD and then with CD that forms the pattern associated with an adult diagnosis of psychopathy or antisocial personality. Although only about 25 to 40 percent of cases of early-onset CD go on to develop adult antisocial personality disorder, over 80 percent of boys with early-onset CD continue to have multiple problems of social dysfunction (in friendships, intimate relationships, and vocational activities) even if they do not meet all the criteria for antisocial personality disorder.
Psychosocial Factors causing conduct disorder
-). Children who are aggressive and socially unskilled are often rejected by their peers, and such rejection can lead to a spiraling sequence of social interactions with peers that exacerbates the tendency toward antisocial behavior
-he combination of rejection by parents, peers, and teachers leads these children to become isolated and alienated. Not surprisingly, they often turn to deviant peer groups for companionship, at which point a good deal of imitation of the antisocial behavior of their deviant peer models may occur.
- family setting of a child with CD is typically characterized by rejection, harsh and inconsistent discipline, and parental neglect (Frick, 1998). There is some evidence that parental behavior can inadvertently “train” antisocial behavior in children—directly via coercive interchanges indirectly via lack of monitoring and consistent discipline
treatments for ODD and CD
Parent management training,
an approach in which the clinician teaches the parents how to effectively prompt and reinforce prosocial behaviors while ignoring aggressive or antisocial behaviors, has been shown to be quite successful. In addition, a separate approach in which the clinician meets with the child to teach social problem-solving skills (such as how to generate and perform more adaptive responses to others) also has proven effective. The combination of these two approaches is especially successful at decreasing child conduct problems, with effects lasting well after treatment has ended
Enuresis
refers to the habitual involuntary discharge of urine, usually at night, after the age of expected continence (age 5). In the DSM-5, functional enuresis is an elimination disorder described as bed-wetting that is not organically caused. Children who have primary functional enuresis have never been continent; children who have secondary functional enuresis have been continent for at least a year but have regressed.
-Enuresis may result from a variety of organic conditions, such as genetic predisposition, disturbed cerebral control of the bladder, or excessive production of urine during the night
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CAUSES OF enuresis
(1) failure to learn how to inhibit reflexive bladder emptying; (2) psychological immaturity, associated with or stemming from emotional problems; (3) disturbed family interactions, particularly those that lead to sustained anxiety; and (4) stressful events
medical treatment of enuresis
-Medical treatment of enuresis typically centers on using medications such as the antidepressant drug imipramine. The mechanism underlying the action of the drug is unclear, but it may simply lessen the deepest stages of sleep to light sleep, enabling the child to recognize bodily needs more effectively
-intranasal desmopressin (DDAVP) has also been used to help children manage urine more effectively= hormone replacement, apparently increases urine concentration, decreases urine volume, and therefore reduces the need to urinate.
encopresis
escribes a symptom disorder of children who have not learned appropriate toileting for bowel movements after age 4. This condition, classified under elimination disorders in DSM-5, is less common than enuresis; however, DSM-based estimates are that about 1 percent of 5-year-olds have encopresis.
TREATMENT: Many children with encopresis suffer from constipation, so an important element in the diagnosis is a physical examination to determine whether physiological factors are contributing to the disorder. The treatment of encopresis usually involves both medical and psychological aspects. Several studies of the use of conditioning procedures with children with encopresis have reported moderate treatment success; that is, no additional incidents occurred within 6 months following treatment (Friman et al., 2008). However, research has shown that a minority of children (11 to 20 percent) do not respond to learning-based treatment approaches
Neurodevelopmental disorders
are a group of conditions characterized by an early onset and persistent course that are believed to be the result of disruptions to normal brain development
Attention-deficit/hyperactivity disorder (ADHD)
is characterized by a persistent pattern of difficulties sustaining attention and/or impulsiveness and excessive or exaggerated motor activity
- children with ADHD often score approximately 7 to 15 points lower on intelligence quotient (IQ) tests
-They often exhibit specific learning disabilities such as difficulties in reading or learning other basic school subjects. Children and adolescents with ADHD also are at significantly higher risk of a range of school problems including suspension and repeating a grade, and these effects appear to be due in large part to disruptive behavior problems
-The rate of ADHD is much higher in boys (13 percent) than in girls (4 percent) (Merikangas et al., 2010) and is commonly comorbid with other externalizing disorders such as ODD and CD (Beauchaine et al., 2010; Frick & Nigg, 2012). ADHD is seen in cultures all around the world.
-half of children with ADHD will continue to meet criteria in adulthood
Causal Factors in Attention-Deficit/Hyperactivity Disorder
-Children with ADHD have smaller total brain volumes than those without ADHD
-brains appear to mature approximately 3 years more slowly than those without ADHD (Shaw et al., 2007). Interestingly, these maturational delays are most prominent in prefrontal brain regions involved in attention and impulsiveness
medications and long term prognosis aDHD
- research has shown that stimulants have a quieting effect on children—just the opposite of what we would expect from their effects on adults. For children with ADHD, stimulant medication decreases overactivity and distractibility and, at the same time, increases their alertness
-Ritalin also seems to lower the amount of aggressiveness in children with ADHD
-Recent studies have shown that there are long-term benefits associated with the use of stimulants among both children and adults with ADHD. For instance, although those with ADHD are at significantly elevated risk of substance use disorders later in life, those who took stimulants during childhood have a lower risk of substance use disorders during adulthood (Dalsgaard et al., 2014). Moreover, adults with ADHD are at significantly increased risk of outcomes such as car accidents and suicide attempts; however, the risk of these outcomes is significantly reduced when these adults are using ADHD medications
side effects of ritalin
decreased blood flow to the brain, which can result in impaired thinking ability and memory loss; disruption of growth hormone, leading to suppression of growth in the body and brain of the child; insomnia; psychotic symptoms; and others. Although amphetamines do not cure ADHD, they have reduced the behavioral symptoms in about one-half to two-thirds of the cases in which medication appears warranted.
extended-release methylphenidate (C
Newer variants of the drug, referred to as extended-release methylphenidate (Concerta), have similar benefits and are available in doses that may better suit an adolescent’s lifestyle
rs. Pemoline i
s chemically very different from Ritalin (Faigel & Heiligenstein, 1996); it exerts beneficial effects on classroom behavior by enhancing cognitive processing and has fewer adverse side effects than Ritalin
Strattera
), a noncontrolled treatment option that can be obtained readily, is a U.S. Food and Drug Administration (FDA)-approved nonstimulant medication (FDA, 2002). Side effects include decreased appetite, nausea, vomiting, and fatigue. The development of jaundice has been reported, and the FDA (2004) has warned of the possibility of liver damage from using Strattera
Adderall.
This medication is a combination of amphetamine and dextroamphetamine; however, research has suggested that Adderall provides no advantage or improvement in results over Ritalin or Strattera
why has autism rates been reportedly increased
. However, the reported increase in autism in recent years is likely due to methodological differences between studies and changes in diagnostic practice and public and professional awareness rather than an increase in prevalence
when is autism typically diagnosed
Autism is usually identified before a child is 30 months of age, and diagnostic stability over the childhood years is quite high. Lord and colleagues (2006) report that children diagnosed with autism by age 2 tend to be similarly diagnosed at age 9. Recent research suggests that early signs of problems with social communication can be detected in the first 6 months of an infant’s life
looking behavior and autistic infants
hildren later diagnosed with autism show a significant decline in their focus on the eyes of others from 2 to 6 months of age and this decline continues until 24 months—at which point it is approximately half the level of focus as that seen in typically developing children (see Figure 15.6; Jones & Klin, 2014). In contrast, while their attention to other people’s eyes decreases, infants later diagnosed with autism show a significant increase in their focus on inanimate objects, which is double the level of typically developing children by 24 months.
SOCIAL symptoms of ASD
-Children with autism often do not show any need for affection or contact with others: HOWEVER t children with autism do express emotions and should not be considered as lacking emotional reactions
-seeming inability of children with autism to respond to others as a lack of social understanding—a deficit in the ability to attend to social cues from others. Indeed, neuroimaging studies have revealed that children with autism show decreased activity in the medial prefrontal cortex, a region associated with understanding the mental states of others, but increased activation in the ventral occipitotemporal regions involved in object perception
Speech symptoms ASD
Children with autism often have an absence or severely limited use of speech. If speech is present, it is almost never used to communicate except in the most rudimentary fashion, such as by saying “yes” in answer to a question or by the use of echolalia—the parrot-like repetition of a few words. Whereas the echoing of parents’ verbal behavior is found to a small degree in normal children as they experiment with their ability to produce articulate speech
sameness and self-stimulation in ASD
Self-stimulation is often characteristic of children with autism. It usually takes the form of such repetitive movements as head banging, spinning, and rocking, which may continue by the hour.
Maintaining Sameness
Many children with autism become preoccupied with and form strong attachments to unusual objects such as rocks, light switches, or keys. When their preoccupation with the object is disturbed—for example, by its removal or by attempts to substitute something in its place—or when anything familiar in the environment is altered even slightly, these children may have a violent temper tantrum or a crying spell that continues until the familiar situation is restored.
Causal Factors in Autism
- Twin and sibling studies have shown that there is a very strong heritable component in autism.
-enetic risk is inherited (52 percent) a
De novo mutations and ASD
are those that occur in the egg or sperm and are passed on to every cell in the child’s body, despite not appearing in the parents’ DNA. It seems that much of the risk for autism is indeed inherited from one’s parents
Outcomes of Autism
discrimination-training strategies (reinforcement) and contingent aversive techniques (punishment).
behavioral intervention administered via one-on-one meetings with the child for over 40 hours per week for 2 years resulted in extremely positive results. The intervention was based on both discrimination-training strategies (reinforcement) and contingent aversive techniques (punishment). The treatment plan typically enlists parents in the process and emphasizes teaching children to learn from and interact with “normal” peers in real-world situations. Of the treated children in the study by Lovaas and colleagues, 47 percent achieved normal intellectual and educational functioning, compared with only 2 percent of children in the untreated control condition.
ASD and Early Start Denver Model (ESDM) intervention
The ESDM intervention involves more than 20 hours per week of intensive behavioral work with the child and parent(s) focused on interpersonal exchanges, verbal and nonverbal communication, and adult sensitivity to children’s cues. Children receiving the ESDM intervention also showed greater cortical activation when viewing other people’s faces (compared to objects), which in turn was correlated with greater improvements in the children’s social communication (Dawson et al., 2012). Although treatments like this one are extremely time consuming, their powerful results suggest that behavioral interventions can cause improvements in people diagnosed with autism.
tic i
is a persistent, intermittent muscle twitch or spasm, usually limited to a localized muscle group.
-Moreover, the age of onset (average 7 to 8 years old) and predominant gender (male) of cases were reported to be similar across cultures (Turan & Senol, 2000). A recent study on the prevalence of tic disorder in children and adolescents reported that the lifetime prevalence of tic disorders (TDs) is 2.6 percent for transient tic disorder (TTD), 3.7 percent for chronic tic disorder (CTD), and 0.6 percent for Tourette’s disorder
Tourette’s disorder,
motor disorder in the neurodevelopmental disorders section of DSM-5, is an extreme tic disorder involving multiple motor and vocal patterns. This disorder typically involves uncontrollable head movements with accompanying sounds such as grunts, clicks, yelps, sniffs, or words. Some, possibly most, tics are preceded by an urge or sensation that seems to be relieved by execution of the tic. Tics are thus often difficult to differentiate from compulsions, and they are sometimes referred to as “compulsive tics”
-coprolalia, which is a complex vocal tic that involves the uttering of obscenities. Some people with Tourette’s disorder also experience explosive outbursts
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habit reversal training or HRT and tics
involves several sequential elements, beginning with awareness training, relaxation training, and the development of incompatible responses, and then progressing to cognitive therapy and modification of the individual’s overall style of action (Chang, Piacentina, & Walkup, 2007). Because children with Tourette’s disorder can have substantial family adjustment and school adjustment problems, interventions should be designed to aid their adjustment and to modify the reactions of peers t
medications and tourettes
Among medications, antipsychotic and noradrenergic drugs are most effective for the treatment of Tourette’s and tic disorders (Hollis et al., 2016). A common concern, however, among parents of children with these disorders is that it can be difficult to find specialists with experience treating them, both in terms of knowing the most effective behavioral interventions and the most effective medications to use for these conditions/ AI Overview
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Antipsychotics are effective in treating Tourette’s syndrome because they primarily work by blocking dopamine receptors in the brain, which is believed to be overactive in individuals with Tourette’s, leading to the involuntary muscle movements (tics) that characterize the disorder; by reducing dopamine activity, antipsychotics can help to lessen the severity of these tics
Learning disorders
delays in cognitive development in the areas of language, speech, mathematical, or motor skills that are not necessarily due to any demonstrable physical or neurological defect.
dyslexia,
, the individual has problems in word recognition and reading comprehension; often he or she is markedly deficient in spelling and memory
causal factors in learning disorders
Probably the most widely held view of the causes of specific learning disorders is that they are the products of subtle CNS impairments. In particular, these disabilities are thought to result from some sort of immaturity, deficiency, or dysregulation limited to those brain functions that supposedly mediate, for normal children, the cognitive skills that children with learning disorders cannot efficiently acquire. For example, many researchers believe that language-related learning disorders such as dyslexia are associated with a failure of the brain to develop in a normally asymmetrical manner with respect to the right and left hemispheres. Specifically, there appears to be dysfunction in the left hemisphere’s reading network among people with dyslexia
-Some investigators believe that the various forms of learning disorder, or the vulnerability to develop them, may be genetically transmitted. This issue seems not to have been studied with the same intensity or methodological rigor as in other disorders, but identification of a gene region for dyslexia on chromosome 6 has been reported
phonics instruction and reading disabiltiies
which involves teaching children letter–sound correspondence as well as how to decode and create syllables, is associated with significant improvements in reading and spelling abilities
Intellectual disability
characterized by deficits in general mental abilities, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience
-By definition, any functional equivalent of intellectual disability that has its onset after age 17 is considered to be “dementia” rather than intellectual disability. The distinction is an important one because the psychological situation of a person who acquires a pronounced impairment of intellectual functioning after attaining maturity is vastly different from that of a person whose intellectual resources were below normal throughout all or most of his or her development.
-he prevalence of diagnosed intellectual disability in the United States is estimated to be about 1 percent
Initial diagnoses of intellectual disability
most frequently occur at ages 5 to 6 (around the time that schooling begins for most children), peak at age 15, and drop off sharply after that. For the most part, these patterns in age of first diagnosis reflect changes in life demands. During early childhood, individuals with only a mild degree of intellectual impairment, who constitute the vast majority of those with intellectual disability, often appear to be normal.
mental retardation, and DSM 5
One noteworthy revision in DSM-5 is the removal of the term mental retardation, which was used in describing individuals with intellectual impairment in previous editions of the DSM. The term mental retardation has come to be considered derogatory by many. The new term, intellectual disability, has replaced mental retardation and is becoming more commonly used by professionals, by the lay public, and by various advocacy groups. As noted by the DSM-5 committee, a U.S. legal statute (Public Law 111-256 or Rosa’s Law) has replaced the term mental retardation with intellectual disability
Individuals with mild intellectual disability AND IQ
have IQ scores ranging from 50–55 to approximately 70 (i.e., more than two standard deviations below the mean) and constitute by far the largest number of those diagnosed with this condition
mild, moderate, severe and profound disability
Mild disability 50–55 to approximately 70
Moderate disability 35–40 to 50–55
Severe disability 20–25 to 35–40
Profound disability Below 20–25
Moderate Intellectual Disability
Individuals with moderate intellectual disability have IQ scores ranging between 35–40 and 50–55 and, even in adulthood, attain intellectual levels similar to those of average 4- to 7-year-old children. Although some can be taught to read and write a little and may manage to achieve a fair command of spoken language, their rate of learning is slow, and their level of conceptualizing is extremely limited
Severe Intellectual Disability
Individuals with severe intellectual disability have IQ scores ranging from 20–25 to 35–40 and commonly suffer from impaired speech development, sensory defects, and motor handicaps. They can develop limited levels of personal hygiene and self-help skills, which somewhat lessen their dependency, but they are always dependent on others for care. However, many profit to some extent from training and can perform simple occupational tasks under supervision.
Profound Intellectual Disability
Useful speech, if it develops at all, is rudimentary. Severe physical deformities, CNS pathology, and retarded growth are typical; convulsive seizures, mutism, deafness, and other physical anomalies are also common. These individuals must remain in custodial care all their lives. Unfortunately, they also tend to have poor health and low resistance to disease and thus a short life expectancy. Severe and profound cases of intellectual disability can usually be readily diagnosed in infancy because of the presence of obvious physical malformations, grossly delayed development (e.g., in taking solid food), and other obvious symptoms of abnormality. These individuals show a marked impairment of overall intellectual functioning.
Genetic-Chromosomal Factors in intellectual disabiltes
Genetic-chromosomal factors play a much clearer role in the etiology of relatively infrequent but more severe types of intellectual disability such as Down syndrome (discussed in more detail later) and a heritable condition known as fragile X (Huber & Tamminga, 2007; Schwarte, 2008). The gene responsible for fragile X syndrome (FMR-1) was identified in 1991 (Verkerk et al., 1991). In such conditions, genetic aberrations are responsible for metabolic alterations that adversely affect the brain’s development. Genetic defects leading to metabolic alterations may also involve many other developmental anomalies besides intellectual disability
Infections and Toxic Agents intellectual disabilties
A number of toxic agents such as carbon monoxide and lead may cause brain damage during fetal development or after birth (Kaski, 2000). Similarly, if taken by a pregnant woman, certain drugs, including an excess of alcohol (West et al., 1998), may lead to congenital malformations. And an overdose of drugs administered to an infant may result in toxicity and cause brain damage. In rare cases, brain damage results from incompatibility in blood types between mother and fetus. Fortunately, early diagnosis and blood transfusions can minimize the effects of such incompatibility.
PHYSICAL INJURY) and intellectual deficitd
Physical injury at birth can result in intellectual disability (Kaski, 2000). Although the fetus is normally well protected by its fluid-filled placenta during gestation, and although its skull resists delivery stressors, accidents that affect development can occur during delivery and after birth. Difficulties in labor due to malposition of the fetus or other complications may irreparably damage the infant’s brain. Bleeding within the brain is probably the most common result of such birth trauma. Hypoxia—lack of sufficient oxygen to the brain stemming from delayed breathing or other causes—is another type of birth trauma that may damage the brain.
Ionizing Radiation and intellectual disabilities
In recent decades, a good deal of scientific attention has focused on the damaging effects of ionizing radiation on sex cells and other bodily cells and tissues. Radiation may act directly on the fertilized ovum or may produce gene mutations in the sex cells of either or both parents, which may lead to intellectual disability among offspring. Sources of harmful radiation were once limited primarily to high-energy X-rays used in medicine for diagnosis and therapy, but the list has grown to include nuclear weapons testing and leakages at nuclear power plants, among others.
MALNUTRITION AND intellectual diasbility
It was long thought that dietary deficiencies in protein and other essential nutrients during early development of the fetus could do irreversible physical and mental damage; however, data in this area so far are inconclusive. A recent review of observational studies that tested the association between maternal weight/nutrition and cognitive functioning in their offspring, as well as experimental studies that tested the potential benefits of providing pregnant women with nutritional supplements (e.g., vitamins, iron, protein), found no clear links between maternal nutritional status and offspring cognitive functioning
No. 18 trisomy syndrome
peculiar pattern of multiple congenital anomalies, the most common being low-set malformed ears, flexion of fingers, small jaw, and heart defects Autosomal anomaly of chromosome 18
Tay-Sachs disease
Hypertonicity, listlessness, blindness, progressive spastic paralysis, and convulsions (death by the third year) Disorder of lipoid metabolism, carried by a single recessive gene
Turner’s syndrome
In females only; webbing of neck, increased carrying angle of forearm, and sexual infantilism; intellectual disability may occur but is infrequent/ Sex chromosome anomaly (XO)
Klinefelter’s syndrome
In males only; features vary from case to case, the only constant finding being the presence of small testes after puberty Sex chromosome anomaly (XXY)In males only; features vary from case to case, the only constant finding being the presence of small testes after puberty Sex chromosome anomaly (XXY)
Niemann-Pick’s disease
Onset usually in infancy, with loss of weight, dehydration, and progressive paralysis Disorder of lipoid metabolism
Bilirubin encephalopathy
Abnormal levels of bilirubin (a toxic substance released by red cell destruction) in the blood; motor incoordination frequent Often, Rh (ABO) blood group incompatibility between mother and fetus
Rubella, congenital
Visual difficulties most common, with cataracts and retinal problems often occurring together, and with deafness and anomalies in the valves and septa of the heart The mother’s contraction of rubella (German measles) during the first few months of her pregnancy
Down syndrome
- the best known of the clinical conditions associated with moderate and severe intellectual disability.
a condition that creates irreversible limitations on intellectual achievement, competence in managing life tasks, and survivability
-. It also is associated with health problems in later life such as pneumonia and other respiratory infections. - The eyes appear almond shaped, and the skin of the eyelids tends to be abnormally thick. The face and nose are often flat and broad, as is the back of the head. The tongue, which seems too large for the mouth, may show deep fissures. The iris of the eye is frequently speckled. The neck is often short and broad, as are the hands. The fingers are stubby, and the little finger is often more noticeably curved than the other fingers. Although facial surgery is sometimes tried to correct the more stigmatizing features, its success is often limited
characheristics of down syndrome
. Although children and adolescents with Down syndrome show deficits in their verbal abilities, language skills, and attention/executive functioning, relative to children with other intellectual disorders, those with Down syndrome show lower rates of other forms of psychopathology, lower levels of family stress, and a more cheerful and positive personality style—each of which could serve as strengths in their everyday functioning (Grieco et al., 2015).
The reason for the trisomy of chromosome 21,
The reason for the trisomy of chromosome 21 is not clear, and research continues to address the potential causes (Korbel et al., 2009), but the defect is probably related to cognitive deficit (Kahlem, 2006) and to parental age at conception. It has been known for many years that the incidence of Down syndrome increases (from the 20s on) with increasing age of the mother. A woman in her 20s has about 1 chance in 1,000 of conceiving a Down syndrome baby, whereas the risk for a woman in her 40s is more than 1 in 100 (Loane et al., 2013). As in the case of all birth defects, the risk of having a baby with Down syndrome also is high for very young mothers, whose reproductive systems have not yet fully matured. Research has indicated that the father’s age at conception is also implicated in Down syndrome, with higher ages conferring greater risk (Andersen & Urhoj, 2017).
phenylketonuria (PKU)
a baby appears normal at birth but lacks a liver enzyme needed to break down phenylalanine, an amino acid found in many foods. The genetic error results in intellectual disability only when significant quantities of phenylalanine are ingested, which is virtually certain to occur if the child’s condition remains undiagnosed (Grodin & Laurie, 2000). This disorder, which occurs in about 1 in 12,000 births (Deb & Ahmed, 2000), is reversible (Embury et al., 2007); however, if it is not detected and treated, the amount of phenylalanine in the blood increases and eventually produces brain damage.
-The disorder usually becomes apparent between 6 and 12 months after birth, although symptoms such as vomiting, a peculiar odor, infantile eczema, and seizures may occur during the early weeks of life. Often, the first symptoms noticed are signs of intellectual disability, which may be moderate to severe, depending on the degree to which the disease has progressed. Lack of motor coordination and other neurological problems caused by the brain damage are also common, and often the eyes, skin, and hair of untreated patients with PKU are very pale
-For a baby to inherit PKU, both parents must carry the recessive gene. Thus, when one child in a family is discovered to have PKU, it is especially critical that other children in the family be screened as well. Also, a pregnant mother with PKU whose risk status has been successfully addressed by early dietary intervention may damage her at-risk fetus unless she maintains rigorous control of phenylalanine intake.
macrocephaly (
“large-headedness”), for example, there is an increase in the size and weight of the brain, an enlargement of the skull, visual impairment, convulsions, and other neurological symptoms resulting from the abnormal growth of glial cells that form the supporting structure for brain tissue.
microcephaly/ primary vs secondary
is defined by a head circumference that is more than three standard deviations below that of children of the same age and sex and is caused by decreased growth of the cerebral cortex during infancy (as skull size during infancy is determined by brain growth) (Woods, 2004). Primary microcephaly refers to decreased brain growth during pregnancy, and secondary microcephaly refers to decreased brain growth during infancy. Children with microcephaly fall within the moderate, severe, and profound categories of intellectual disability and most show little language development and are extremely limited in mental capacity.
causes of microcephly
Approximately half of these were caused by genetic factors, 45 percent were the result of brain damage in utero (e.g., due to factors such as maternal disease or birth complications), and 3 percent were caused by brain damage after birth. It is important to note that the cause of microcephaly is completely unknown in about 40 percent of cases, and so much additional research is needed to better understand this condition.
hydrocephaly
is a relatively rare disorder in which the accumulation of an abnormal amount of cerebrospinal fluid within the cranium causes damage to the brain tissues and enlargement of the skull (Materro et al., 2001). In congenital cases, the head either is already enlarged at birth or begins to enlarge soon thereafter, presumably as a result of a disturbance in the formation, absorption, or circulation of the cerebrospinal fluid. The disorder can also arise in infancy or early childhood following the development of a brain tumor, subdural hematoma, meningitis, or other conditions. In these cases, the condition appears to result from a blockage of the cerebrospinal pathways and an accumulation of fluid in certain brain areas.
=In chronic cases, the chief symptom is the gradual enlargement of the upper part of the head out of proportion to the face and the rest of the body. Although the expansion of the skull helps minimize destructive pressure on the brain, serious brain damage occurs nonetheless. This damage leads to intellectual impairment and to such other effects as convulsions and impairment or loss of sight and hearing. The degree of intellectual impairment varies, being severe or profound in advanced cases.
treatment hydrocephaly
Hydrocephaly can be treated by a procedure in which shunting devices are inserted to drain cerebrospinal fluid. With early diagnosis and treatment, this condition can usually be arrested before severe brain damage has occurred (Duinkerke et al., 2004). Even with significant brain damage, carefully planned and early interventions that take into account both strengths and weaknesses in intellectual functioning may minimize disability
mainstreaming or “inclusion programming”
. For children with mild intellectual disability, the question of what schooling is best is likely to challenge both parents and school officials. Many such children fare better when they attend regular classes for much of the day. Of course, this type of approach—often called mainstreaming or “inclusion programming”—requires careful planning, a high level of teacher skill, and facilitative teacher attitudes
applied behavior analysis,
moderate and severe disabilities
applied behavior analysis, including structured reinforcement programs that teach and strengthen adaptive behaviors, have shown especially strong promise to effectively help those with intellectual disability
treatment for children and lack of parental consent
(1) in the case of mature minors (those considered capable of making decisions about themselves); (2) in the case of emancipated minors (those living independently, away from their parents); (3) in emergency situations; and (4) in situations in which a court orders treatme
Vulnerabilities that Place Children at Risk for Developing Emotional Problems
Physical or sexual abuse, parental divorce, family turbulence, and homelessness can place young people at great risk for emotional distress and subsequent maladaptive behavior
-Parental substance abuse also has been found to be associated with the vulnerability of children to the development of psychological disorders (Bijttebier & Goethals, 2006), and children from homes with harsh discipline and physical abuse are more likely to be aggressive and to have conduct disorder than those from homes with less harsh discipline and from nonabusing families
four types of facilities young victims of abuse, neglect, and related conditions.
(1) foster homes, (2) private institutions for the care of children such as group homes, (3) county or state institutions, and (4) the homes of relatives.
The quality of a child’s new home is, of course, a crucial determinant of whether the child’s problems will be alleviated or made worse, and there is evidence to suggest that foster home placement has more positive effects than group home placement
Causal Factors of juvenile delinquency
Brain Damage and Learning Disability
In a distinct minority of delinquency cases (an estimated 1 percent or less), brain pathology results in lowered inhibitory controls and a tendency toward episodes of violent behavior. Such adolescents are often hyperactive, impulsive, emotionally unstable, and unable to inhibit themselves when strongly stimulated.
Psychological Disorders
Some delinquent acts appear to be directly associated with behavior disorders such as ODD, CD, or ADHD.
Antisocial Traits
Many habitual delinquents appear to share the traits typical of antisocial personalities (Bailey, 2000). They are impulsive, defiant, resentful, devoid of feelings of remorse or guilt, incapable of establishing and maintaining close interpersonal ties, and seemingly unable to profit from experience.
Drug Abuse
Many delinquent acts—particularly theft, prostitution, and assault—are directly associated with alcohol or drug use (Leukefeld et al., 1998). Many adolescents who abuse hard drugs such as heroin are forced to steal to maintain their habit. In the case of female addicts, theft may be combined with or replaced by prostitution as a means of obtaining money.
Parental Absence or Family Conflict
Delinquency appears to be much more common among youths from homes in which parents have separated or divorced than among those from homes in which a parent has died, suggesting that parental conflict may be a key element in causing delinquency.
Parental Rejection and Faulty Discipline
In many cases, one or both parents reject a child. When the father is the rejecting parent, it is difficult for a boy to identify with him and use him as a model for his own development. However, the detrimental effects of parental rejection and inconsistent discipline are by no means attributable only to fathers. Adolescents who experience alienation from both parents have been found to be more prone to delinquent behavior (Leas & Mellor, 2000).
Undesirable Peer Relationships
Delinquency tends to be an experience shared by a cultural group
multisystemic therapy and juvenile delinquincy
a comprehensive intervention in which the clinician attempts to make changes in several of the systems that influence delinquent behavior, including the adolescent’s family, peer network, school, and community
